Provider Demographics
NPI:1235180100
Name:BEAVER BROOK PEDIATRIC & ADOLESCENT MEDICINE, P.C.
Entity Type:Organization
Organization Name:BEAVER BROOK PEDIATRIC & ADOLESCENT MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANTONIONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-891-3706
Mailing Address - Street 1:465 WAVERLEY OAKS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8438
Mailing Address - Country:US
Mailing Address - Phone:781-891-3706
Mailing Address - Fax:781-891-3564
Practice Address - Street 1:465 WAVERLEY OAKS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8438
Practice Address - Country:US
Practice Address - Phone:781-891-3706
Practice Address - Fax:781-891-3564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110074250AMedicaid
MAM2183501Medicare PIN